External and middle ear Flashcards
(121 cards)
1
Q
4 types of OE
A
- Acute Otitis Externa (AOE)
- Chronic Otitis Externa (COE)
- Malignant or Necrotizing Otitis Externa
- Herpes Zoster Oticus (Ramsey-Hunt)
2
Q
2 types of AOE
A
- Diffuse - “Swimmer’s Ear”
- Pseudomonas MC - Localized - Furunculosis
- Infection of a hair follicle
- Staph aureus typically
3
Q
2 types of COE
A
- Otomycosis
- Infection with a fungal species - Non-infective
4
Q
pt presents with
Itching
Severe pain
Conductive hearing loss
Feeling of fullness or pressure
they’ve been swimming a lot this summer
what could it be?
A
AOE - diffuse
5
Q
during an otoscope exam you see
Purulent discharge
Pain with palpation of tragus or traction of auricle (classic sign)
Swollen, red canal
Moist debris in canal
TM difficult to visualize
what could it be?
A
AOE - diffuse
6
Q
tx for AOE - diffuse
A
- Thoroughly clean ear canal to remove debris
- Hypertonic saline solution - Topical antibiotics
- Ofloxacin (Floxin) otic soln or Ciprofloxacin
- Cortisporin Otic soln or susp (Neomycin, Polymyxin B, Hydrocortisone)
- Cipro HC or CiproDex otic soln
- 5 drops BID or TID - Pain relief
- Avoid promoting factors
- cx if severe, or no resolution - Ear wick
- Placed in swollen canal
- Helps distribute medicine and keep medicine in canal
- Expands as its moistened
7
Q
Tx for severe or immunocompromised AOE - diffuse
A
Systemic antibiotic and / or steroids
Ciprofloxacin 500mg BID for 1 week
8
Q
infection of hair follicle is what kind of AOE?
A
Furunculosis
lateral ⅓ of canal
9
Q
MC pathogen that causes furunculosis
A
staph aureus
10
Q
tx for AOE - furunculosis
A
- Oral Dicloxacillin or Cephalexin (Keflex)
- I&D if needed
11
Q
Fungal infection of the ear canal
Can arise from previous abx in ear/hot, humid climates
A
Chronic Otitis Externa - Otomycosis
12
Q
Ear itching, discomfort, discharge, foreign body sensation in ear
Deep seated itching is most troublesome
is associated with what condition
A
Chronic Otitis Externa - Otomycosis
13
Q
Edema less severe than bacterial
May resemble mold growing on spoiled food
associated with soft, white, sebaceous-like material that may fill ear canal
what condition is this?
A
Otomycosis
14
Q
tx for Otomycosis
A
Cleaning of canal
Cotrimazole 1% solution BID 10-14 days
15
Q
non-infective COE is repeated local irritation from what conditions?
A
- Seborrheic Dermatitis
- Psoriasis
- Contact Dermatitis
- Shampoo, cosmetics, ototopical medications
16
Q
pt seen with a Canal that is red, scaly and dry
they have a hx of seborrheic dermatitis
what condition could their ear be having?
A
COE - noninfective
17
Q
tx for Chronic Otitis Externa - Non-infective
A
Topical Hydrocortisone cream/otic drops
18
Q
Potentially life-threatening
Infections spreads from skin to bone and marrow spaces of the skull base
A
COE - Malignant/Necrotizing
Misnomer= it is not neoplastic process
19
Q
COE - Malignant/Necrotizing MC causative organism
A
pseudomonas
20
Q
Malignant/Necrotizing COE is MC in what kind of pts?
A
Elderly patients with Diabetes Mellitus
Immunocompromised patients
21
Q
for the past several months, your pt has experiencing a temporal HA, and has been smelling a foul odor from their ear
you exam and see Severe, deep seated otalgia out of proportion to examination findings
what could be this condition?
A
COE- Malignant/Necrotizing
22
Q
Granulation tissue at the bony cartilaginous junction of the ear canal floor
is the hallmark finding for what?
A
COE - malignant/necrotizing
23
Q
complications with Chronic Otitis Externa - Malignant/Necrotizing
A
- Spread to base of skull - osteomyelitis
- Spread to meninges and brain
- CN involvement - cranial nerve palsy
- Thrombosis of sigmoid sinus
- High mortality rate
24
Q
how do you diagnose COE - malignant/necrotizing
A
- CT scan
- Determine extent of disease via demonstration of osseous erosion - BX of granulation tissue
25
tx for COE - malignant/necrotizing
1. Aggressive glycemic control
- IV and oral Antibiotics 6 - 8 weeks typically required:
- **_Ciprofloxacin 200-400mg BID_** 1st line
- **Piperacillin, Cefepime (Maxipime)**
- Treat until clinical improvement seen
2. Selected patients may be graduated to oral ciprofloxacin
- **Ciprofloxacin 500 - 1000 mg BID**
- Treat until gallium (nuclear) scan is clear of inflammation (generally 6-8 weeks)
3. Surgical debridement
- In severe, refractory cases only, not usually needed
26
Herpes zoster infection of geniculate ganglion
Sensory ganglion of facial nerve
COE - Herpes Zoster Oticus
Ramsay Hunt Syndrome
27
Unilateral facial nerve (CN VII) palsy, severe otalgia, vesicular eruption on the face
Altered taste and tongue lesions sometimes noted
May be indistinguishable from Bell’s palsy if paralysis precedes rash
Chronic Otitis Externa - Herpes Zoster Oticus
Ramsay Hunt Syndrome
28
tx for Chronic Otitis Externa - Herpes Zoster Oticus
Steroids and antivirals
Prednisone _and_ Famciclovir (Famvir) or Valacyclovir (Valtrex)
29
what is the protective secretion produced by outer portion of ear canal
cerumen
30
how is the ear canal self-cleaning
Outer layer of skin sheds
Wax goes with it
31
what causes cerumen impaction?
self-induced
Recommended hygiene only consists of cleaning external opening with a washcloth over the index finger
32
indications for cerumen impaction removal
Difficulty examining the TM
Otitis externa
Work-up for hearing loss
Suspected ear canal pathology
Patient request
33
contraindications for cerumen impaction removal
Presence or history of perforated TM
Previous pain on irrigation
Previous surgery of the middle ear or mastoidectomy
Uncooperative patient
Very hard cerumen
34
techniques for cerumen impaction removal
1. Irrigation
- Water at body temp to avoid a vestibular caloric response
- Direct stream at ear canal adjacent to cerumen plug
- Dry canal with hair dryer on low power or rubbing alcohol - Reduces likelihood of external otitis
2. Mechanical removal
- Ear curette
3. Microsuction
4. In-home therapy
- 3% hydrogen peroxide
- Detergent ear drops OTC - **Debrox, Cerumenex**
35
Ear FB is MC in who?
children
36
removal of ear FB?
1. Irrigation
- Avoid if organic foreign body that can expand when moistened (think beans or insects)
2. Mechanical
- Alligator forceps or ear curette
3. Living insects
- Immobilize first with lidocaine
37
Collection of blood under the perichondria
Connective tissue found covering the surfaces of cartilages
auricle hematoma
38
auricle hematoma results from ?
direct trauma to the anterior auricle
39
if untreated auricle hematoma can progress to what?
“Cauliflower ear” or “Wrestler’s Ear”
40
tx for auricle hematoma
1. Within 7 days, otherwise refer
- Prevents significant cosmetic deformity
2. Lidocaine 1%: auricle block
3. I&D
4. Irrigate pocket with NS
5. Compression dressing x 7 d
6. Re-examine every 24 hrs
7. Avoid NSAIDS
8. Antibiotic prophylaxis +/-
41
goal tx for auricle hematoma
Evacuate subperichondrial blood
Prevent its reaccumulation
42
goal tx for auricular lac
Cover exposed cartilage
Minimize wound hematoma
43
what examinations do you do for auricular lacs
TM, External auditory canal
Facial nerve
Basilar skull fracture
Hearing deficit
44
management for auricular lac
1. Tetanus vaccine if indicated
2. Antibiotics if:
- Contaminated wound
- Bite injuries
- Signs of inflammation
3. Primary closure is preferred
45
technique for primary closure of an ear lac
1. Anesthesia
2. Debridement
3. Copious Irrigation
4. Suture
5. Packing
- Xeroform strips into ear crevices
--- Petrolatum occlusive dressing
6. Compression dressing
7. Recheck 24 hours
8. Sutures out in 4 - 5 days
46
when to refer auricular lac
Refer to plastic surgery
1. Large skin avulsions (5 mm or >)
2. Severe crush injuries
3. Complete or near complete avulsion
4. Auricular hematoma
5. Large cartilage defect (> 5 mm)
6. Wounds that require removal of > 5 mm tissue
7. Involvement of auditory canal
8. Tissue devitalization
47
Swollen, erythematous, hot external ear lobule from Minor trauma, insect bite, or ear piercing
Auricular Cellulitis
48
tx for Auricular Cellulitis
1. Oral abx
- Cephalexin
- TM-SX (MRSA)
- Clinda (MRSA)
2. IV abx - severe
- vancomycin
--- Tachycardia
--- Rapid progression of erythema
--- Progression despite oral abx
--- Systemic toxicity (fever >100.5)
3. Warm compresses
4. NSAIDS for pain management
49
Infection of the perichondrium of the auricular cartilage where the lobe is less involved
Due to local trauma, surgery, burns
Perichondritis
50
what causes ear deformity in perichondritis
interruption to blood supply to cartilage
51
perichondiritis can rapidly progress to what other serious condition
necrosis of cartilage
52
MC causative pathogen of perichondritis
pseudomonas
staph aureus
53
tx for perichondritis
1. Want to start within 5 days
- Risks hospitalization and deformity
2. Oral or IV Ciprofloxacin
3. I&D
54
Fluid in the middle ear
is what condition
Middle ear effusion
54
Fluid in the middle ear
is what condition
Middle ear effusion
55
Acute infection of the middle ear fluid
is what condition
Acute otitis media
56
Middle ear fluid that is NOT infected
Also called “serous otitis media”
Frequently precedes OM or follows its resolution
Otitis media with effusion
57
what do you document when describing the TM?
1. Comment on color, translucency (clearness) and if intact.
2. Commenting on pertinent negatives is also appropriate - ie - No erythema, no bulging, no retraction, no drainage.
3. If mobility is assessed, then also comment on mobility (ie - TM clear, intact, and mobile).
58
An acute, suppurative, infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the inner ear space
Acute Otitis Media
59
AOM is MC in who?
1. sick children
- 60 - 80% of children have at least one episode by 1 year old
- 80 - 90% by 2 - 3 years old
2. Most prevalent in infancy
60
Most common reason for antibiotic use
AOM
61
what can reduce AOM incidence
pneumococcal vax
62
risk factors for AOM
1. Age
- Peaks between 6 - 24 months
2. Family History
3. Daycare
4. Lack of breastfeeding
5. Tobacco use
6. Seasonal
7. Altered host defenses and underlying disease
8. Pacifier use
63
what condition generally always precedes AOM?
URI
64
what preserves middle ear conditions through clearance of middle ear fluid, ventilation, and protection from nasopharyngeal reflux
Eustachian tube
65
how does an Impaired function of the Eustachian tube lead to AOM?
1. retention and suppuration of retained secretions
2. Dysfunction induces a negative pressure in the middle ear space
- Negative pressure followed by accumulation of secretions produced by the middle ear mucosa
3. Viruses and bacteria that colonize the upper respiratory tract enter the middle ear
66
MC pathogenic causes of AOM
1. **Streptococcus pneumonia MC**
2. Haemophilus influenzae
- More with bilateral otitis media
- Conjunctivitis
3. Moraxella Catarrhalis
- 10% of cases
67
which bacterial cause of AOM is
More common in older children
More local complication
Group A streptococcus
68
which bacterial cause of AOM causes Acute otorrhea in children with tympanostomy tubes
Staphylococcus
69
which bacterial cause of AOM is responsible for AOM in the first months of life?
e. coli
70
which bacterial cause of AOM is responsible for chronic, suppurative OM
pseudomonas
71
which bacterial cause of AOM is MC in infants younger than 2 wks
GABHS
72
what viruses can cause AOM
1. Respiratory Syncytial Virus (RSV)
2. Picornaviruses
- Rhinovirus
- Enterovirus
3. Coronaviruses
4. Influenza
5. Adenoviruses
6. Human Metapneumovirus
73
clinical s/s of AOM
1. Ear pain
- MC but not always present
2. Non-specific signs and symptoms
- Cough, congestion, **Fever**, irritability, HA, anorexia, N/V/D, ear tugging, decreased hearing
3. **Bulging of TM**
4. Mobility of TM
- Poor mobility when pneumatic pressure is applied using a pneumatic otoscope
5. erythema of TM or otalgia
74
what distinguishes AOM from OM with effusion
bulging of TM in AOM
75
middle ear effusion would present how?
TM suppurative opacity
Decreased or absent TM mobility
- Pneumatic otoscopy
- Tympanometry
Otorrhea
76
fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous TM
is seen in what condition
middle ear inflammation
77
tx for mild-moderate AOM
1. Initial therapy
- **Amoxicillin** 875mg BID
- Cefdinir (Omnicef) 300mg BID
- Cefuroxime (Ceftin) 500mg BID
- Azithromycin (Zithromax) 500 PO Day 1, then 250 QD PO on Days 2-5
--- Lack activity against most H. flu and ⅓ of pneumococcal isolates
2. exposure to abx within 30 d / tx failure after 72 hrs
- Amoxicillin plus Clavulanate 875mg (**Augmentin** ES or XR) PO in divided doses BID,
- **Cefdinir** (Omnicef) 300mg BID
- Ceftriaxone (Rocephin) 1g-2g IM daily for 3 days, _OR_
- Clinda 30-40 mg/kg/d PO in divided doses TID
78
if the pt is allergic to PCN what else could you tx for AOM
1. **Cephalosporins** - recommended to those who _do not have anaphylaxis_
- Cefdinir
- Ceftriaxone
2. **Zithromax or doxy** - recommended _for immediate PCN hypersensitivity_, such as anaphylaxis.
79
tx for severe AOM
1. Initial therapy or with associated bacterial conjunctivitis (Likely H. Influenza)
- Augmentin ES
- Ceftriaxone (Rocephin)
2. exposure to abx within 30 d / tx failure
- Ceftriaxone (Rocephin)
- Clindamycin
- Consider tympanocentesis
Duration of all meds
- 10 d - patients < 6 y/o and/or with severe disease, TM perforation or recurrent AOM
- 5 - 7 d (with consideration of observation only in previously healthy individuals with mild disease) - ≥ 6 y/o
Failure to improve and/or clinical worsening in 48 - 72 hours needs re-evaluated
80
when would you need referral for AOM
for ENT - Tympanostomy Tubes
1. 3 or > AOM within 6 months
2. 4 or > AOM within 12 months
3. Unresponsive to pharmacological treatment regime
81
complications for AOM
1. Hearing loss
2. Balance and motor problems
3. TM perforation
4. Tympanosclerosis
5. Chronic suppurative OM
6. Cholesteatoma
7. Ossicular fixation
8. Extension of suppurative process to adjacent structures
- Mastoiditis
9. Intracranial complications
- Meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis
82
prevention of AOM
1. Encourage breastfeeding
- IgA is secreted through breastmilk
- Offers protective qualities
2. Upright for bottle feedings
3. Avoid passive smoke exposure
4. Limit exposure to groups of children
5. Careful hand washing
6. Avoid pacifier use >10 months old
- Constant sucking action exacerbates eustachian tube dysfunction
- Causes auditory tubes to become abnormally open
--- Allows secretions from the throat to seep into middle ear
--- This transmission of bacteria in the secretions can lead to middle ear infections
3. ***_Immunizations_***
83
Otitis media complications
1. Bullous Myringitis
2. TM rupture
3. Tympanosclerosis
4. Chronic Suppurative OM
5. Chronic otitis media
6. Cholesteatoma
7. Mastoiditis
84
Associated with AOM with bullae present on the TM
Bullous Myringitis
85
tx for Bullous Myringitis
1. same as AOM
2. may need atypical coverage
- Mycoplasma
Zithromax
86
Rupture accompanied by sudden decrease in pain, followed by otorrhea
Tympanic Membrane Rupture
87
tx TM rupture
1. Audiogram to check hearing
- Now and repeat in 3 months
2. Oral and Topical antibiotics
- Oral same as AOM - Amoxicillin, Augmentin, Cefdinir
- Low ototoxicity topical Ab - Ofloxacin, Ciprodex
3. Earplugs - Swimming and bath
4. Spontaneous resolution
- Weeks to months
5. Tympanoplasty if no resolution
88
When describing a perforation, you must describe:
1. Location (o’clock)
2. Give idea of size of perforation
3. Also comment if there are any signs of infection
89
Scar on the TM
Tympanosclerosis
90
Consequence of recurrent OM
Presence of perforation of the TM with chronic purulent drainage from the middle ear for >6 weeks (otorrhea)
Chronic Suppurative OM
91
what can exacerbate chronic suppurative OM?
URI or after swimming
92
what bacterial causative agents are responsible for Chronic otitis media
1. Pseudomonas
2. Proteus
3. S aureus
4. mixed anaerobic infections
93
tx for chronic OM
1. Meds
- Topical Ab: Ofloxacin/Cipro + dexamethasone for exacerbations
- Oral: Ciprofloxacin 500 mg BID X 1-6 weeks
2. Removal of debris, use earplugs to protect against water exposure
3. Definitive management = surgical
94
TM surgical repair may be accomplished with what muscle?
temporalis muscle fascia
95
Abnormal growth of squamous epithelium in middle ear and mastoid
May enlarge to surround and destroy the ossicles
Cholesteatoma
96
what causes Cholesteatoma
1. Due to chronic negative pressure in the middle ear
2. MC - Prolonged eustachian tube dysfunction
97
clinical findings of cholesteatoma
Typically erode bone
1. Deep retraction pockets
2. White mass behind the TM
3. Focal granulation at the TM periphery
4. Can become chronically infected
5. Ear drainage for >2 weeks despite treatment
6. Hearing loss - conduction - due to ossicular erosion
98
tx for cholesteatoma
Refer - surgery
Surgical marsupialization or removal
99
Occurs after several weeks of untreated or inadequately treated OM
Pus filling the air cells
Mastoiditis
Mastoid air cells connect with middle ear
Erosion of the surrounding bone
Formation of abscess-like cavities
100
fluid found in the middle ear is almost always with fluid in where?
mastoid
101
pt presents with
Pain, erythema and swelling over mastoid process with proptosis
Fever
what could their condition be?
Mastoiditis
s/s of AOM too
102
complications with mastoiditis
Subperiosteal abscess
Deep neck abscess
Septic thrombosis of lateral sinus
103
cx of a mastoiditis could show what?
Similar to AOM
S. pneumoniae, H. flu, S. pyogenes, S. aureus
Gram negative bacilli, including Pseudomonas
104
how could you diagnose mastoiditis
CT scan
105
tx for mastoiditis
1. IV abx x 7-10 d
- Ceftriaxane
- Cefazolin
2. oral abx
- Augmentin
- Cefdnir
3. Myringotomy: Surgical drainage of TM
4. Surgery if tx fails: mastoidectomy and debridement
106
function of eustachian tube
Provides ventilation and drainage for the middle ear
Normally opens only during yawning or swallowing
107
MC causes of eustachian tube dysfunction
1. **Viral URI MC**
2. Allergies
3. Edema of the tubal lining
108
s/s of Auditory “Eustachian” Tube Dysfunction
1. Symptoms
- Fullness in ear
- Mild to moderate hearing impairment
- Partially blocked tube - swallowing or yawning creates popping or crackling sound
2. Signs
- Retraction of TM and decreased mobility on pneumatic otoscopy or tympanometer
Lasts days to weeks following a viral infection
109
tx for Auditory “Eustachian” Tube Dysfunction
1. Systemic and intranasal decongestants
2. Autoinflation by forced exhalation against closed nostrils
3. Allergies
- Intranasal steroids
4. Avoid air travel and altitude change, underwater diving
110
Most acute during plane descent/deep sea diving
what condition
barotrauma
Negative middle ear pressure tends to collapse and lock the auditory tube
Painful if tube collapses
Underwater diving more stressful to ear than flying
Descent
111
Middle Ear Space is air-filled: subject to pressure changes
Unable to equalize the barometric stress on middle ear during air travel, rapid altitude change, or underwater diving
Barotrauma
112
prevention of barotrauma
1. Do not dive with conditions that can lead to ET dysfunction: viral URI
2. Swallow, yawn, and auto inflate often during descent
3. Systemic decongestants several hours before arrival
4. Topical decongestants 1 hour before arrival
113
tx for barotrauma
1. Oral decongestants taken several hours before arrival time or topical decongestant 1 hr before
2. Attempt autoinflation
3. Myringotomy
4. VT tubes if patient flies often and has severe symptoms
114
underwater diving barotrauma can cause what other additional findings
1. Hemotympanum
2. Perilymphatic fistula
- Rupture of oval or round window connecting middle/inner ear
--- Sensory hearing loss and acute vertigo
--- Emesis - due to acute labyrinthine dysfunction
115
you should not go diving if you are experiencing these symptoms:
URI or allergies
TM perforation
116
Bony overgrowths of the ear canals d/t benign tumors
Skin-covered mounds in medial ear
Exostoses and Osteomas
117
Multiple exostoses is acquired how?
repeated exposure to cold water
often need surgery
118
Mc causatives of neoplasia of ear canal
1. **Squamous cell carcinoma**
2. OE - does not resolve - biopsy
119
what ear condition has high morality rate and why?
neoplasia of ear canal
Tumor tends to invade lymphatic of cranial base
120
Adenomatous tumors originate from where?
ceruminous glands
More indolent
